[104-10222-10012.pdf — page 299]
# DECLARATION OF APPOINTEEThis form is to be completed before entrance on duty. Answer all questions. Any false statement in this declaration will be grounds for cancellation of application or dismissal after appointment. Impersonation is a criminal offense and will be prosecuted accordingly.1. PRESENT ADDRESS (street and piimber, and sing   1000 Greig St - #25J - Seat Pleasant, Md.Colly or town and State of county)OmahaCpraskaIN CARE OF EVENGENCY PLEASE NOTMrs Jean Randall wifeSTREET AND NUMBER CITY AND STATE7000 Font Md. 10-99126DOES THE UNITED STATES GOVERNMENT EMPLOY, DE A CIVILIAN CAPACITY, ANY RELATIVE OF YOURS (EITHER BY BLOOD OR MARRIAGE WITHTHEMONTHS YES21 so, foc pack such relative All in the blante dobar. Il. additional space is necessary. complote undie Item 10.POST OFFICE ADDRESSMrs Jean Randall 7000 Grey, SMTCOLCCIPicosentEVDVAL V2 10 DECTION DE VOLONLEE(1)POSITION TEMPORARY OR NOT(2) DEPARTMENT OR AGENCY IN WHICH EMPLOYEDPersonal clerkI. R. SRELATIONBIED(CheckoWifeLOLLICEINDICATE "YES" OR "NO" ANSWER BY "ANSWER BY PLACING T IN PROPER COLUMN3. ARE YOU A CITIZEN OF ON DO YOU OWE ALLICIANCE TO THE URUTED STATESIARE YOU AN OFFICIAL OR EMPLOYEE OF ANY STATE TERRITORY, COUNTY OR MUNICIPALITYIf your answer is "Yes", give details in Item ta7. DO YOU RECEIVE ANY ANRUITY FROM THE UNITED STATES OR DISTRICT OF COLUMBIA GOVERNMENT UNDER ANY RETIREMENT ACT OR ANY PENSION OR OTHER COMPENSATION FOR MILITARY OR NAVAL SERVICEIf your answer is" You", give in Item 10 reason for retirement, that is de optional disability, or by ms of voluntaryor involuntary separation after Speare, carvi mount of retirement per, and under whit rotirement act, and fatia if retired from military or πονάλ πετικα& SINCE YOU FILED A YOUR FILED APPLICATION RESU ATKIN RESULTING IN THIS THIS APPOINTMENT HAVE YOU BEEN DISCHARGED, OR FORCED TO RESIGN, FOR MISCONDUCT OR URSATIS FACTORY SERVICE FROM ANY POLITICIf your answe: le"You", dive in Item 10 the name and a of employer, date and resson in each9. MAVE YOU BEEN ARRESTED (BOT ULCLUDING TRAFFIC VIOLATIONS POS WHICH YOU WERE FINED 12 OR LESS, OP FOR FITES CALATERAL OF 125 OR LESS, SINCE YOU FILED APPLICATHAN REBLE TING IN THIS APPOINT MENT?Il your ans nowar is "You", list all ouch casos under Item-10. Give in onchspase: (1) The date; (2) the nature of the affenes of violation; (3) the veme and location of the court. (5) ING penalty imposed, af ny, or other disposition cừ tho caca Ti appointede your Engni peinte will be taken.YES NO ONXXXXXITEN NO.10 SPACE FOR DETAILED ANSWERS TO OTHER QUESTIONSWRITE IN LEFT COLUMN NUMBER ITENS TO WHICH DETAILED ANSWERS APPLYINSTRUCTIONS TO APPOINTING OFFICERThe oppointing officer Before whont the forgate certificate lo made shall determine to his own sat faction that this appiwat cent souble in conformance Bith the Civil Service Act, oppilicable Civil Βέρνικο ate of Congress, crtsining.to appointmentThis form silould bereked for boiling of office, prosion, suntability is eco- דילים with any rees of rocent ducharge of aircut, and particularly for the following:(!) Hontity of appointee. It is the daty of the appointing offers to gund aoine tonererention and to deteremias beyond reamcacle doubt that the tatre is the same perem winate appeter was authored. The matres store and handwriting are to be compared with the app de se and other pertinent papere, If the appaatre gustead in a writes exact βείτια της εγure on the foran, ahould be cocert at the signature on the dribration Whert, but was agnol in theper may be chevised against the medical ceste. The appointce may ao questioned on his personal bistory foot with his privice(1) Ago -If définit ege Smits have been established for the prottion, it should be determined that epohsent is not out to the age rinse for appointment. Until such deterom stron is made the eppostnret majy nie be cassianmetal(3) Citizenship The accinting, offices to responsible or observing the eituenship provtares of (1) the Civil Service Rules and (1) appmpmarina arts Form of cenazuules an affidavit for both purposes and is anepestle proof of citireship status in the absence of conti ting cadre. In dateful fairs the appointment should not be consummates and clearance has bατά αυτώτα στο the certifying ulice of the Cird Service Common(1) Members of Pamity Sortion of the Cird Service Act provides that wwertige se 'ready two more estabers of family nerving under probation of portresent anwentinent in the some but wher Feinberghie te perhatical or secara totit h the competitore wine Reamets persons retto دب perftesine web tais requiremental provins dare not apply temporary puntmeate Dobfidcre my be istared to Savere Comisarines for dec一空ダー